Specialists and Practice Guidelines: On the Cash Cow in the Room

Here’s a personal story about medical overuse and willful ignorance. Stay tuned for the punchline.

First, a little background: a couple of weeks ago I came across a great study on medical overuse, specifically adherence to national recommendations published in 2012 regarding the use of the PSA (prostate specific antigen) blood test to screen for prostate cancer.

Here’s the PSA story: In 2012 the United States Preventive Services Task Force (USPSTF) updated its guidelines to recommend that men generally not be PSA screened for prostate cancer. The recommendation was made after the committee weighed the effectiveness of the screening in reducing mortality from prostate cancer versus the consequences of treating an working up a bunch of red herrings. The guidelines note:

There is… convincing evidence that a substantial percentage of men who have asymptomatic cancer detected by PSA screening have a tumor that either will not progress or will progress so slowly that it would have remained asymptomatic for the man’s lifetime. The terms “overdiagnosis” or “pseudo-disease” are used to describe both situations.

…existing studies adequately demonstrate that the reduction in prostate cancer mortality after 10 to 14 years is, at most, very small, even for men in what seems to be the optimal age range of 55 to 69 years. There is no apparent reduction in all-cause mortality. In contrast, the harms associated with the diagnosis and treatment of screen-detected cancer are common, occur early, often persist, and include a small but real risk for premature death.

The USPSTF concludes that there is moderate certainty that the benefits of PSA-based screening for prostate cancer do not outweigh the harms.

Subsequently, the Clinical Guidelines Committee of the American College of Physicians (ACP) recommended that clinicians inform men ages 50 to 69 about the limited potential benefits and substantial harms of prostate cancer screening and only screen men who express a clear preference for being screened. The guidance statement also recommends against screening for prostate cancer in average-risk men under the age of 50 and against screening in men over the age of 69 or with a life expectancy less than 10 to 15 years.

How effective were these recommendations from the nation’s blockbuster guidelines groups? In the April 2016 JAMA Internal Medicine, authors found something interesting:

The study, performed by Brigham and Women’s authors, Michael Zavaski and colleagues, used a national dataset to examine PSA testing in 2010 (before the guidelines) and 2012 (after). They included all visits for men ages 50 to 74 who went to urologists or primary care physicians for a preventive care visit. The authors found that PSA testing decreased from 36.5 percent in 2010 to 16.4 percent in 2012 among primary care physician visits (significant difference) but only decreased from 38.7 in 2010 to 34.5 in 2012 percent among urologist visits (not significant). Here are the the results.

So, what could explain this steep difference between PCPs and specialists? I’ve heard a range of explanations, from the suggestion that the urologic guidelines were a bit more lenient than the USPTF and ACP, to the old saw about how when you’re a hammer everything looks like a nail, to the JAMA author’s own diplomatic conclusions:

“Moving forward, this finding emphasizes the need to continue interdisciplinary dialogue to achieve a broader consensus on prostate cancer screening”

My thinking on this “practice variation” issue has evolved. In 2014, I commented on Jack Wennberg’s findings on practice variation, commenting on how deeply held physician belief systems guide particular therapies.

“as much as 36 percent of end-of-life Medicare expenditures, and 17 percent of overall Medicare expenditures, could be explained by physician beliefs that cannot be justified either by patient preferences or by clinical effectiveness”.

Last year, in American Healthcare post, I commented on the on growing use of prophylactic coiling for cerebral aneurysms despite indications that it wasn’t doing anything for the incidence of subsequent sub-arachnoid hemorrhages from burst aneurysms. My take at the time: physicians are far more sensitive to missed badness than overaggressively pursued nothingness.

For these kinds of population-level tradeoffs to work — for thousands of people to benefit from the avoidance of unnecessary care — there needs to be some small number of unlucky souls who would have benefitted from the treatment or workup but didn’t get it. Statistically, it has to work that way.

Nobody wants to be that unlucky soul… And, for our part, physicians are hardwired to over-value the impact of missing a rare case of cancer while under-valuing the cummulative benefits of avoided testing. It’s primal.

The highly-polite professionals (urologists, in fact) authoring this report declined to address the cash cow in the room. Simply put, the more PSAs, the more abnormal PSAs, the more (urological) procedures to be done. Look, the alternative is that urologists simply do not share other doctors’ faith in evidence-based medicine, as exemplified by the objective scientists empaneled at the USPSTF. Or, they are too dense to absorb this simple advisory, pointing out that routine PSA tests do more harm than good.

What a shame I didn’t read the USPTF guidelines before visiting my urologist last month.

I periodically visit a private-practice urologist who has monitored a chronic condition for a couple of years. On my last visit I was seen by the urology PA, who at the end of the visit recommended that we perform a prostate exam and a send a PSA.

I looked at him skeptically: I’m in my 40’s with no risk factors. Is this really indicated, I asked?

I could make any decision I wanted, the PA explained, but their office sent PSAs and did prostate exams on almost all patients. He would recommend that I get tested “just in case.”

In all candor: this was one of those times when I wished that I had read the instructions in advance. But, in the rush of a busy afternoon (and convinced that the urologist must know more than me about urology issues), I hastily agreed. We sent a PSA and did a prostate exam. Both were normal.

Now, of course, the problem is that no single consensus document that I could find, anywhere, endorses screening PSA (or prostate exams) in average-risk men in their 40s. Remember, this isn’t about controversy in screening older adults, where a urologist could maybe disagree with the guidelines. This was testing that was completely unsupported by science.

Which is a disappointing reflection on my urologist’s professional competence, and which gets us back to Dr. Ross’s suggestion that this is all about the cash.

How much money changed hands while I was getting my totally normal prostate checked? More than you’d think: It turns out that the urologist has the Quest lab in the building’s basement do venipuncture and to run a couple of samples. But, curiously, they also ask Quest to send send several tubes blood back to the urologist’s office to be run on the office’s point of care lab machines. I simply can’t come up with a clinical reason why the office would insist on running the labs internally rather than have Quest do it more cheaply.

According to my insurance company, here are the invoices and payments made for the 20 minute visit: You can see how profitable office-run labs (including PSA) are.

Item

Billed

Allowed

Urology Office Visit

$250

$65

Quest Labs for Venipuncture and Bloodwork

$489

$53

Urologist-run Labs at Point of Care

$365

$177

$1,104

$295

Imagine the cash that flows when the PSA is abnormal and biopsies need to be done. It’s fee-for-service working exactly as designed.

In the absence of reasonable specialist self-regulation, only two things will stem this flood of low value specialty care: either as a system we migrate to a risk-bearing payment models where primary care physicians are incentivized to advocate for their patients and who select specialists on the basis of their thoughtful practice of medicine. Or, we need to insist that the insurance company refuse to pay for un-indicated tests and for things like point of care labs.

Absent that, the system of misaligned financial incentives under fee-for-service seems to irreparably affect specialist’s judgement.

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“Managing capitation can be deceiving. Like flying an airliner, the gauges, levers and controls can make it seem like high-stakes science. It is, partly. But as with all things healthcare this is ultimately about humans, their needs and their behaviors. You eventually learn that managing the payment model is as much an art as is the actual practice of medicine”.